Home Visitor Monthly Activity Log Instruction Sheet



Home Visitor Monthly Activity Log

Instruction Sheet

|Column |What to Enter |

|Family ID # |Enter the identification number assigned to the family at intake |

|# of HV Attempted |Indicate the total number of home visits that were attempted including those that were completed and |

| |those that were scheduled but did not happen. You would include those visits that were scheduled but the|

| |family cancelled. You would not include those visits that were scheduled but the Home Visitor cancelled.|

|# of HV Completed - Curriculum Used |Indicate the number of home visits that actually took place in the home, whether or not they were |

| |scheduled and curriculum was used. Home visits should last a minimum of 30 minutes and a maximum of one |

| |hour (except for special circumstances). Visits lasting less than 30 minutes should not be counted. |

|# of HV Completed - Curriculum Not Used |Indicate the number of home visits that actually took place in the home, whether or not they were |

| |scheduled and curriculum was not used. Home visits should last a minimum of 30 minutes and a maximum of |

| |one hour (except for special circumstances). Visits lasting less than 30 minutes should not be counted. |

|Creative Outreach? |Indicate if the family was placed on creative outreach at anytime during the month being reported. |

| |Should be answered Yes or No. |

|# of Office/Other Individual Visits Completed |Indicate the number of visits that occurred outside of the home. In this column, you should only |

| |document visits in which HV covered similar material that she would cover in a home visit (i.e. |

| |curriculum, parent-child interaction, etc.). You would not count casual visits with moms where you did |

| |not discuss any program related materials. |

|# of referrals made this month |Enter the number of referrals you made to another agency or program for any member of the household |

|Name of Agency Family Referred To |Indicate the name of the agency the member of the household was referred to |

|Referral Code |Enter only the number of the following codes to represent the places where referrals are made. If you |

| |are not sure which category a referral fits into, please call Meredith Damboise at (860) 523-9644. |

| |1. WIC 11. Mental Health/Counseling |

| |2. DSS 12. Crisis Intervention |

| |3. Social Security 13. Parenting class/program |

| |4. Food Needs 14. Substance Abuse |

| |5. Doctor/Medical services 15. Domestic Violence |

| |6. Housing needs 16. Employment |

| |7. Legal Needs 17. Education |

| |8. Household Needs 18. Dept. of Children & Families |

| |9. Child Care 19. Recreation |

| |10. Cultural/Religious 20. Other |

|Was Referral Followed-Up by Family? |Indicate if the family member followed up on the referral or not. If you cannot find this information |

| |out by the time the month is completed, make sure to put the results on the next months form. Should be |

| |answered Yes, No or Don't Know (DK) |

Home Visitor Monthly Activity Log

Instruction Sheet

|Column |What to Enter |

|Indicate if this was an old referral from previous |Indicate if this was an old referral from a previous month. Should be answered Yes or No. |

|month? | |

|Parent(s) volunteered in/at the school |Indicate if the parent has volunteered in or at the school during the month. Should be answered Yes, No|

| |or Don't Know (DK) |

|Parent(s) participated in PTO/PTA |Indicate if the parent has participated in a PTO/PTA meeting during the month. Should be answered Yes, |

| |No or Don't Know (DK) |

|Parent(s) took child(ren) to library |Indicate if the parent has taken any of the children in the household to the public library during the |

| |month. Should be answered Yes, No or Don't Know (DK) |

|Parent(s) participated in school sponsored event |Indicate if the parent has attended a school sponsored event (i.e. a school meeting, performance, |

|(Y/N/DK) |workshop, etc.) during the month. Should be answered Yes, No or Don't Know (DK) |

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